The cultural threshold of pain

In
2009, for the first time, U.S. deaths linked
to drug
abuse exceeded those caused by road accidents (see chart), according to the Federal agency of the U.S. Government "Centers
for Disease Control and Prevention ", which in 75% of cases points the
finger at the inappropriateness of prescriptions. The
main cause of medicines abuse is the dependence
on analgesics in the opioid family. These are in fact the
category of drugs most prescribed in the United States and in the last
ten years the number of units prescribed has almost quadrupled.
The major problem is that often their
side effects or the risks associated with an
out-of-control use of these drugs has been underestimated.

"Drug-related" includes both legal and illegal substances. In the period 1999-2008
rates of death by overdose, sales and hospitalization
linked to the abuse of opioid analgesics (OPR= opioid pain reliever)
increased significantly. Compared to 1999, in 2008 the number of
deaths from drug overdoses nearly doubled. Similarly, sales of
opioids quadrupled in 2010 compared to 1999 data.
(Source: Centers for Disease Control and Prevention).

Until
15 years ago, these drugs were almost exclusively used
for the treatment of pain in the postoperative phase or in
terminal cancer patients. It was precisely on the basis of the good results obtained in
controlling pain in those cases, that opioids began
to be prescribed to patients suffering from chronic pain.
This most recent use prompted pharmaceutical companies to
propose new, targeted formulations. Sales, last year,
reached $ 8.5 billion, twice the figures reached
in 2001 (data: IMS Health). The situation is truly alarming
also due to the recreational use, especially by
adolescents, of drugs such as oxycodone, developed to
alleviate the most intense forms of pain, but increasingly involved in
a growing illicit trade.

Something
however is changing and the lead State this time is that of
Washington, which placed limits and stricter controls on the
prescription of pain medications - a significant and difficult
change not only for patients, but also for physicians.
Indeed the battle has to be fought mainly in hospitals and in
practitioners' offices, rather than in the street. What is often left unsaid, like a taboo,
is that it is the doctors who overdo with prescriptions, giving in
to the pressing demands of
patients who have developed an addiction. The risks of using
painkillers include sleep apnea, falls and bone fractures
in the elderly but, in extreme cases, death by overdose. For
this reason, legislators in the Washington State, last year
imposed new requirements on physicians prescribing opioids.
The Centers for Disease Control and Prevention invited them to
be more cautious when prescribing them, emphasizing that just in 2008
overdose deaths were 14,800. It is indeed paradoxical that
a practice that was started to relieve patients' pain ends up
even causing their death.

The analysis
of the files of patients who died from overdose shows failure to
perform the required drug tolerance monitoring
by physicians. Often those who suffer from chronic pain are affected by
concomitant conditions that need special attention (anxiety,
depression) and that do not improve by simply increasing the
drug dosage. Several scientific studies have since
shown the risks associated
with the abuse of opioid drugs which, for example, suppress the
production of sex hormones, altering the physiology of
patients well beyond the mere sexual sphere. Other
research highlighted the benefits of alternative,
non-pharmacological therapies, effective in many cases. However,
despite the heated debate and the
accusations of "cruelty" (from patient groups, pharmaceutical
companies and insurance companies), in the State of Washington
a law was passed establishing a threshold in
the dosage of medication prescribed (equivalent to 120 milligrams of
morphine per day), above which the use of a
commission of experts is activated.

Physicians will certainly need to follow specific training courses to be able to
judge which molecule and what dosage to prescribe and for which
indication, in addition to learning how to handle cases of dependency and
abstinence.Among the professionals most at risk of error
there are, undoubtedly, emergency doctors who often have
neither the time nor the means to judge whether the patient who is complaining, for
example, of a terrible toothache is telling the truth. When in
doubt, the doctor prescribes the drug, because a denied prescription
in cases of genuine necessity becomes the basis for an
.adverse evaluation of the work of the professional.
A research conductedby the National
Hospital Ambulatory Medical Care Survey
showed that from 1997 to 2007, painkillers were
prescribed in 3 cases out of 4 during a visit to the dental emergency room
and that the number of
prescriptions related to toothache in this type of
departments increased by 26%.

An
even more worrying area is that of the Maternity Departments which have seen
an increasing number of women addicted to opioids and,
consequently, of infants showing withdrawal symptoms. A
study published in the Journal
of the American Medical Association
quantified the phenomenon and the costs related to it: in the U.S.
every hour a child is born with symptoms of "Neonatal withdrawal syndrome",
therefore, on average, 13,500 infants a year suffer from
the consequences of the abuse of painkillers inappropriately used
by their mothers. From 2000 to 2009 the number of this type of
women giving birth has increased fivefold and the average cost related to assistance
given to their children exceeds 53 thousand dollars for each case.
Symptoms include seizures, respiratory problems,
dehydration, feeding difficulties, tremor and irritability.
These children need long term care and specific therapies based on
methadone and morphine. The worst news is that as of today we do not know
whether any lasting effects can be envisaged for these children
over time.Obviously the best thing is to
prevent the mother's problem, helping her in treating the
addiction to drugs before birth or, better yet, before
pregnancy.
A special medical help is even coming from a video game designed by
scholars of the Faculty of Medicine of Northwestern University and
developed by engineers at Johns Hopkins University, which uses
a technology similar to that used by the FBI to train its agents
for interrogation techniques. The video game will help doctors
recognize the symptoms of opioid dependence during the
interview with the patient, with a series of guided questions and answers.

However,
while overseas the measures (legislative, and not only) to
to fight the abuse
of opioids increase, in Italy the situation is quite different and
the culture of pain shows peculiarities in some respects even
opposite. In March 2010 a law came into force, unanimously passed
earning the applauses of the whole Parliament, with the intent of
promoting "hospitals with no pain". A little over a year after its
enactment, in July 2011, a survey promoted by the Senate Investigation Commission
on the National Health
Service was carried out to
verify its effective implementation throughout the country.
Well, hospitals and physicians throughout the country ignore or
only partially apply the law. The right not to suffer for millions of
Italian is essentially guaranteed only in the North and partly in the
Centre of Italy, while the South is lagging behind. From Rome
down, the use of opioids is left at the starting post: since law 38/2010 has authorized
doctors to use a regular prescription form to prescribe them, their
consumption grew too little (7% in a year), compared to the already
little number of units sold in the past which make Italy one of
the key laggards in Europe. The survey, conducted in 244 hospitals
(86 in the North, 103
in the Center, 55 in the South) used a check-list prepared to
verify, among other things, whether there were any committees or programs
in place for pain control, palliative care units, the use
of forms for evaluating acute and chronic pain,
information material for patients and an active communication network with
general practitioners. The average compliance with the requirements set by the law was
71% with peaks of 88% in the North, 75% in the Centre and 53% in the
South, where, however, at least 5 regions do not reach 50%. These
results show insufficient compliance with the obligations imposed
by law.But above all, they unveil a widespread cultural lag
with respect to the attention paid to pain in Italian hospitals
: an issue that requires urgent consideration and action.